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India’s health system in the COVID crisis


[Translate to en:] Indien Corona
Sri Guru Tegh Bahadar COVID-19 Medical Isolation & Treatment Centre in New Delhi, India. picture alliance / | Pradeep Gaur

For there can now no longer be any doubt that such an epidemic dissemination of typhus had only been possible under the wretched conditions of life that poverty and lack of culture had created in Upper Silesia. If these conditions were removed, I am sure that epidemic typhus would not recur. ... Therefore, I abide by the doctrine which I have placed at the head of this discussion: Free and unlimited democracy.

Rudolf Virchow, Report on the Typhus Epidemic in Upper Silesia, 1848

The second wave of COVID-19 is wreaking havoc across the globe, including in India. The health system in India is in serious crisis, as the central government failed to anticipate or prepare for the second wave despite expert warnings. As of May 2021, India has the second-highest number of confirmed COVID cases in the world after the United States. The second wave of COVID-19 erupted in India in March 2021, and is proving to be much more damaging than the first wave.

On 17 May 2021, India had over 3.5 million active COVID cases, levels which are much higher than the first wave, which reached a nationwide peak in mid-September 2020 at around 1 million active cases. As of 17 May, India had a total of 275,000 COVID deaths, and even those high figures are widely regarded as an underestimate. The media has reported overflowing crematoriums and burial grounds in several areas including the nation’s capital Delhi, with cremation fires burning day and night. In the state of Uttar Pradesh, bodies of deceased COVID patients are being disposed of in the hundreds by dumping them in the Ganges River.

Abhay Shukla and Shweta Marathe work with the civil society organization SATHI, which works on health rights in the context of public and private health care in Maharashtra, India, while having linkages to national campaigns. They thank Dr. Anant Phadke, whose writings were useful while writing this article.

The second COVID wave in India has arrived with massive challenges related to access to health care, with widespread reports of severe shortages of beds, oxygen supplies, essential medicines like Remdesivir, emergency transport and other facilities. There are also numerous reports regarding private hospitals charging exorbitantly and refusing admissions without payment of hefty advances, despite several Indian states directing private hospitals to regulate rates covering 20–80 percent of their beds for COVID patients. Some patients are reported to be grossly overcharged, with costs of daily treatment ranging between 50,000 and 100,000 rupees for hospitalized COVID patients.

The inability to check the rapid rise in cases during the second wave, accompanied by failing health care infrastructure which was ill-prepared to deal with the situation despite the experience of the first wave, needs to be viewed as a monumental failure of governance in India, primarily by the central government.

Missed Opportunities

On 30 January 2020, the World Health Organization (WHO) declared COVID-19 to be a public health emergency. Despite this, the Indian government kept international airports freely open until the third week of March, in which period around 1.1 million travellers returned from abroad without proper testing or follow up. In February 2020, as the COVID epidemic rolled out across India, Prime Minister Narendra Modi was busy entertaining Donald Trump at a gathering of over 100,000 people in the city of Ahmedabad, thus organizing what may have been the first super-spreader event in the country.

While on 13 March 2020 the PM declared that there was “no health emergency”, there was then a sudden about turn, with the abrupt and blanket imposition of a lockdown on the entire country on 24 March with just four hours’ notice. At this point there were no COVID cases in the vast majority of districts and towns across India, meaning that a more differentiated approach to restrictions would have been far more appropriate from public health perspective, while being much less damaging socially.

By mid-2020, it was clear that the number of public hospital beds was in need of a major increase to deal with anticipated COVID patients. The short-term respite gained from the lockdown period should have been used to upscale public health facilities. However, with the central government in the lead, most states did not do this and focused instead on reallocating beds from non-COVID to COVID care. It should be noted that India has just one government doctor per 11,000 people (the WHO norm is 1:1,000), and just 0.5 government hospital beds per 1,000 people (the WHO norm is 3:1,000). Thus, there was a backdrop of insufficient government health facilities, which should have been rapidly upgraded once the first wave receded. This opportunity was missed, with disastrous consequences soon to follow.

Glaring Failures

Global epidemiological evidence showed that a second COVID wave was highly likely. Countries like Vietnam, South Korea, New Zealand, and Japan avoided a second wave through appropriate measures, while the US and Europe anticipated another wave. As a result, most countries managed to control transmission at a lower level. In India, an apex scientific panel (INSACOG) formally warned the government in early March 2021 about its “high concern” that new, more contagious variants of coronavirus were taking hold that could lead to a serious situation. Such highly infectious variants of COVID-19 might have contributed to the rapid second rise of cases in India, as evidenced by a recent official study.

Yet the central government ignored this serious possibility, and the national political leadership led by Modi continued to organize massive election rallies without COVID precautions (especially in the state of West Bengal) throughout March and April 2021. The government actually moved forward the massive “Kumbh” festivities by one year, sanctioning the event in 2021 instead of the planned date in 2022, thus permitting over 7 million people to participate in hugely crowded ritual bathing events until late April 2021, despite the raging epidemic across India. Political compulsions seem to have prevailed over basic public health considerations, while hard-earned lessons from the first wave were ignored. Autocratic misgovernance not only failed to check the second COVID wave, in fact it actively fuelled the epidemic—with fatal consequences. 

Learning from models predicting the second wave, the Indian government should have accelerated the process of increasing hospital beds, infrastructure, and ensuring availability of essential medicines while fast-tracking vaccination, accompanied by preventing large gatherings. Given the experience of the first wave, increased medical oxygen capacity should have been rapidly created. Today, Kerala—which is ruled by a left-wing government that recently returned to power with widespread popular support—is an oxygen-surplus state, having increased its medical oxygen capacity by 60 percent after the first wave through advanced planning and efficient plan execution. By contrast, today there is a critical oxygen shortage in many other states, with the central government floundering, prompting the Supreme Court of India to intervene and set up a task force to ensure transparent and efficient allocation of medical oxygen across the country.

The Chronic Illnesses of the Indian Health System

Concerning the sorry state of India’s health system, the shortcomings of which have been brutally exposed by the pandemic, Arundhati Roy recently observed: “The system has not collapsed. The ‘system’ barely existed. This is what happens when a pandemic hits a country with an almost non-existent public health care system.”

India’s health system is characterized by an under-resourced, under-staffed public health system, combined with overwhelmingly dominant for-profit private health care. India spends just about 1.1 percent of its GDP on health, which is far lower than most countries in the world. With aggressive promotion of neoliberal policies since the 1990s, accelerated under the present political leadership since 2014, India has witnessed growing privatization and corporatization of health care services. 70 percent of health care in India is provided by the private sector, and every year unaffordable, privatized health care pushes 115 million Indians into poverty—a number greater than the population of Germany! Some of the key “illnesses” of India’s health care system, which have been further exposed by the COVID-19 pandemic, include:

  • Understaffed, underfunded public health services in most states, which are inadequate to carry out essential COVID-related preventive and containment measures.
  • Poorly staffed public hospitals which are insufficient compared to the population’s health requirements, leading to inadequate facilities for COVID-19 patients, as well as gaps in general health care services.
  • The unregulated private health care sector continues to dominate the entire health care system, and the regulatory Clinical Establishments Act 2010 is still awaiting effective implementation. Hence, many large private hospitals and laboratories have continued to engage in major overcharging and profiteering, despite some state directives on rate regulation.
  • Along with inequitable and inefficient resource allocations, the system is majorly deficient in social accountability and democratic involvement. During the epidemic, many governments, especially the central government, have operated in a hyper-centralized and inadequately transparent mode. 

Given the urgent need for a strengthened public health system highlighted by the first wave, it was expected that the current year’s national budget would see a major hike in government health spending. However, the Finance Minister presented deceptive figures in the Union Health Budget 2021–22, claiming a major hike in health spending, which on closer examination actually revealed a decline of 11 percent in the actual health budget compared to the previous year’s revised budget.

In January 2021, The Prime Minister of India stated that, “We are launching the world’s biggest vaccination drive and it shows the world our capability.” On the ground, however, there have been massive gaps in the vaccination roll-out. So far less than 3 percent of the population has been fully vaccinated, meaning that the vast majority of the population remains vulnerable to infection. Instead of procuring and supplying COVID vaccines to all states to be administered free of cost for all citizens, today the central government’s vaccine policy is a politicized mess, leading to deep confusion, massive inefficiencies, and extensive vaccine shortages which will continue for many more months. 

Raising Voices to Protect Health Rights

Taking cognisance of health rights violation during the first COVID wave, the National Human Rights Commission (NHRC) issued a wide-ranging “Advisory on the Right to Health” with 59 recommendations in September 2020. Now with the larger number of cases emerging during the second wave, NHRC recently issued a second Advisory on Health Rights. These remarkable advisories on the right to health promote a wide range of entitlements for patients and ordinary people, which, if implemented, would enable them to access required forms of health care while also ensuring the protection of the rights of frontline health care providers. 

At the same time, rights-based civil society networks are demanding improved care and systems in the COVID situation. The People’s Health Movement India, or Jan Swasthya Abhiyan (JSA), a national network of civil society organizations and people’s movements, recently observed a national day of action on 10 May and released a comprehensive statement emphasizing the obligations to be fulfilled by the national and state governments to ensure universal availability and access to health services during the second wave of the pandemic.

In a unique event held in February 2021, the Maharashtra chapter of the People’s Health Movement organized a public hearing on private hospitals, encouraging patients and their caregivers to share experiences regarding exploitative practices in private hospitals during the COVID period. Case documentation of 30 patient testimonies was carried out by the organizers for this event, which was held in a hybrid manner with 130 participants. Powerful testimonies were shared concerning private hospitals relating to overcharging, violating government regulations, denial of free care under health insurance schemes, and violation of basic patients’ rights such as detaining the dead body of patients to extract charges.

With the COVID epidemic acting as a powerful “scanner” for the health system, the stage is being set to launch a powerful movement for far-reaching reforms in the entire health care sector. This would be the most appropriate response to address the yawning systemic gaps which have been revealed during this national crisis.

A Wake Up Call for the Health System

Undoubtedly, the COVID-19 pandemic can become a turning point for the health system in India. Now is the time to reimagine health systems and envision how these can be positively transformed through deep-rooted reforms focused on the following aspects:

  • Massive increase of the public health budget: There has been a long-pending demand for raising the public health budget to reach at least 3 percent of GDP. This must now be fulfilled.
  • Major expansion of public health infrastructure and human resources: Linked with the increase in budget, it is necessary to substantially expand the infrastructure of the system and human resources, based on regular recruitment of adequate staff as well as ensuring proper pay and working conditions to health workers at all levels.
  • Regulation and social accountability of private health care sector: Regulation of the private health care sector in India has been a long-pending demand, which came onto the agenda as various state governments began enforcing regulation of rates in private hospitals. While these unconventional regulatory actions are positive, several private hospitals have resisted these efforts. Widespread complaints of overcharging, problematic quality of care, and unnecessary medications by unregulated private hospitals caution us as to how private hospitals’ profit motives supersede their social obligations—even in times of emergency. It is thus vitally important to develop robust, institutionalized frameworks for regulation and social accountability of private providers, linked with appropriate forms of engagement with the public system. 
  • Reforms for decentralization and democratization: Public health services need to operate in a more decentralized manner, with much greater democratic participation in their planning and implementation. There is a need to develop participatory platforms for health system-community interface, including active community members, local elected representatives, and civil society groups from the village to state levels. Frameworks such as community-based monitoring and planning in Maharashtra need to be generalized as core components of public health, since health programmes initiated from above are much more effective when working in tandem with social mobilization from below.

The unprecedented experience of the COVID-19 pandemic has uncovered the deep-rooted malaise of India’s privatized health care system, which is reeling under autocratic governance. It is now time to develop a powerful movement for Universal Health Care, moving towards a publicly organized, democratized health system which will fulfil the right to health care for all.